Category Archives: Cardiac Ischemia

Question: In the event we have a patient who is STEMI positive, with symptoms of CHF (crackles/pitting edema) who is hypertensive >140 systolic BP are we to treat with 0.8mg of nitro for the CHF or 0.4 mg under the ischemic chest pain protocol? Also with the new STEMI standard dropping down to 3 - 0.4mg SL doses of nitro maximum, will that change out CHF protocol for nitro administration if both problems present together?

Question: In Elgin county we have been having trouble with our defibs spitting out 'noisy data' warnings on our 12 lead ECG's lately which has prompted conversation with crews about the STEMI protocol. Though the protocol clearly states that LP15 ECG software interpretation meets ***MEETS ST ELEVATION... some crews are saying that due to this issue with noisy data, we are able to interpret the ECG on our own and determine if it meets our criteria based on the >1 mm/or the >2mm ST elevation criteria. Your thoughts? Should we patch the cardiologist? Should we transport to nearest ED due to software not recognizing due to noisy data?

Question: I was faced the other day with a question by one of my fellow peers in regards to the administration of nitroglycerine. As a contraindication, it states that we cannot administer nitro of the SBP drops by one third or more of its initial value after nitro is administered. This can be interpreted in 2 different ways, as brought to my attention by my fellow peer so now ever since, I second guess myself. So my question is, this "initial value," is it the very first BP we take even before the first dose of nitro, or is it referring to the initial BP you take AFTER the first dose of nitro. It is such a simple answer I am sure but if I can get clarification so I can also relay the message to my fellow peer that would be great.

Question: I am a ACP student and was discussing among my colleagues the proper time frame for vitals and drug administration for morphine and NTG in the cardiac ischemia medical directive. I understand that each drug has a 5 minute intervals but someone had mentioned that you could stagger both drugs in 5 minute intervals, for example after administering a third NTG wait 5 minutes then morphine then wait 5 minutes then NTG etc. I was wondering what the preferred interval for vital signs and drug administration would be with two drugs staggered at 5 minute intervals.

Question: I have a question in regards to right sided MI's. We had a patient that had slight elevation in his 12 lead inferior leads, but not enough to call for a STEMI. I once worked for a service that I could do a right sided 12 lead ECG. Are we allowed to perform right sided 12 leads here at SWORBHP if we do suspect an inferior MI?

Question: At our recent recertification, I posed a question that was answered by a doctor. This was regarding the ability to call a cardiologist if we had a patient with a STEMI who did not have chest pain. Her answer was: “not at this time”. However, in conversation with medics from other classes, this seems to contradict what they have been told. Can you please clarify?
br>Also, are we to continue to understand that once a patient is out of the STEMI protocol (e.g. with vitals) that they continue to be so even if the vitals improve to within proper range?

Question: My question is in regards to the Cardiac Ischemia protocol. I am currently a PCP student and we had a chest pain call. The patient was complaining of chest discomfort and described it as a pressure starting sub-sternal and going to patient’s left shoulder. The patient was also experiencing SOB. This pain was a 6/10 when it first came on and went down to a 5/10 with relaxation. The patient did not have a history of angina but had received NTG in the hospital a couple years before and did not know the why. The patient did not have NTG on their own list of meds. We gave 2 81mg ASA and did a 12-lead which was negative for a right ventricular infarct. My preceptor did establish an IV and got a line started set at TKVO before we gave the NTG.

The question is even though the patient did not have NTG on their own med list at the time of the call; does the time the patient was in hospital and was given NTG count as prior history for the Cardiac Ischemia protocol?

I did see a related question on the site but it was related to a doctor giving the NTG before EMS arrival and it was stated that it should be prescribed. So does that mean it has to be a current prescription or can a patient have it in the hospital and it count? I know it does not matter after you get an IV establish but if we weren't able to get an IV established then would we have been able to give it?

Question: Your partner is preparing O2, obtaining vitals and attaching the monitor for a chest pain patient. You are performing a primary survey, gathering your SAMPLE Hx, ruling the patient in protocol for ASA, giving the ASA and doing the same for Nitro. Vitals are obtained 3-4 minutes earlier than the Nitro administration.

From past experience and following the protocol which states vitals q5 min, nitro q5 min and vitals must be obtained within 5 minutes of medication delivery, is this improper as 3 minutes has lapsed prior to the nitro administration? I have been informed that past deactivation has resulted from this?

Question: I recently had a patient with ischemic like she's pain (no ECG changes). When going through questions to administer ASA, the patient stated she could not have ASA as per her physician because she was recently placed on Clopidogrel after a stroke about 3 weeks ago. I ask the patient if she meant she should not have daily aspirin, or if a one-time aspirin was okay. She could not answer the question, and stated she did not want to be treated with the aspirin. Is the patient correct, or should I have pushed harder to administer it?

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